Post developed by Lynae Conyers, MD

Case: A 6yo previously healthy girl presents to clinic with her mother with the complaint of body odor and concerns that patient is “developing too early”. Mom reports onset of body odor a few months ago now requiring daily deodorant. Your exam reveals Tanner stage II to III pubic hair and a small amount of axillary hair. What might be going on in this patient? What other information should be obtained from history and physical exam and what are the next steps?

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Precocious Puberty

Definition:

Precocious puberty is the development of secondary sexual characteristics prior to age 8 in girls and prior to age 9 in boys

What physical exam findings herald the onset of puberty?

When does puberty begin?

The onset of puberty is affected by many factors. Puberty typically occurs earlier in girls with early maternal menarche, obesity, and low birth weight. Racial and ethnic background also appears to play a role in the timing of puberty. Several cross-sectional studies in the US have noted earlier onset of puberty in African-American girls as compared to Caucasian girls.(Carel and Lager 2008)

Now that we’ve reviewed normal, let’s return to precocious puberty

How common is precocious puberty?

Precocious puberty is ten times more common in girls than boys.

In the US, the incidence is estimated at 1 in 5,000 to 10,000 girls. (Latronico et al. 2016)

What causes Central Precocious Puberty?

Early activation of pulsatile GnRH secretion. In other words, central precocious puberty is gonadotropin-dependent

TREATMENT:

Treatment is particularly important for younger patients, male patients, and for patients whose skeletal age is advancing more than height age.

GnRH agonists (such as leuprolide) are the most effective medical therapy. Constant stimulation of the pituitary gland with GnRH agonists initially leads to short term pubertal stimulation followed by downregulation of GnRH receptors and decreased gonadotropin production.

Referral to a pediatric endocrinologist is essential. Even those with suspected benign pubertal variants need to be followed over to time to ensure no other evidence of true puberty develops.

Back to our case…

On further questioning, there have been no known exposures to estrogen products or tea tree oil. Review of systems is otherwise negative. Mom reports first menstruating at age 11. In addition the pubic and axillary hair, exam is notable for small breast buds. You review the patient’s growth chart and note she has grown 7cm in the past year. Based on these findings, you are concerned for central precocious puberty. You begin the evaluation with labs (FSH, LH and estradiol) and bone age xrays and arrange for short interval follow-up.